Virtual rounds bring families to bedside

Where: Thomas Jefferson University Hospitals, a system of hospitals with 951 beds in the
Philadelphia region.

The issue: Communicating with inpatients' family members when they cannot be physically present.

Background

When it comes to treatment plans, a lot of information can get lost between early-morning
rounds and visiting hours. “We have found that communication between health
care professionals and families about the patient getting the care is less than optimal,
so we created this program called virtual rounds,” said Judd Hollander, MD,
an ED physician and associate dean for strategic health initiatives at Sidney Kimmel
Medical College at Thomas Jefferson University in Philadelphia.

How it works

Using videoconferencing software similar to a webinar, the program allows family members
to virtually join the health care team at the patient's bedside during rounds. The
family members connect using their own devices, and the inpatient clinicians and patient
can use either the patient's smartphone or one of the tablets kept on units that participate
in the program. “I think the most family members we have engaged is four at
once, all from different states,” said Dr. Hollander.

The program is offered to patients as part of admission instructions, and they can
then opt in or out. Patients schedule virtual rounds with the hospital's telehealth
team, either in advance or on demand, and about a handful occur on a given day, said
Dr. Hollander.

So far, the postanesthesia care unit (PACU) has seen the most success with the program,
said Dr. Hollander. “When people come out of surgery, the family is always
antsy, they're not always there, and even when they're there, they can't go in and
see the patient for a couple hours,” he said. “So we're now able to
connect that patient with their loved ones right as they come out of the OR.”

In addition to making families feel better, the system can potentially improve postdischarge
care. “That way, the family or caregiver who is not sedated and has not just
woken up from sleep gets a chance to listen to that interaction, be part of the discharge
process, and hopefully be able to better help coordinate care when the patient goes
home,” said Dr. Hollander.

Results

A minority of patients take the offer to be on camera. “I think our percentage
of people that take it is around 10%, but those who take it generally love it,”
said Dr. Hollander. He recounted a story of two brothers who hadn't spoken to each
other in six months. “The brother who was actually on hospice care and dying
wanted to do this, and his other brother agreed to do it. . . . The hospitalized patient
couldn't speak anymore, but he was able to give his brother the thumbs up,”
said Dr. Hollander. The next day, the patient's brother wanted to connect again, he
said, but the patient had died overnight. “It was a little bit embarrassing
for the telehealth coordinator, but when they called the brother at a distance back
to inform him, the brother stated that he had interpreted the thumbs-up sign as ‘All
is forgiven’ and was totally at peace with their six months of not speaking,”
Dr. Hollander said.

Challenges

Challenges to the program have been on the physician end. “Some doctors spend
a lot of time with patients and are really, really happy to do it and love this,”
Dr. Hollander said. “Some doctors are in and out of the room, and if the video's
not set up at the exact minute they're going to be there (which is, of course, hard
to coordinate), they don't tolerate that terribly well.”

There can also be difficulty finding a time to talk that fits families' schedules
and physicians' workflows. “With many things in telemedicine, it's not actually
about the technology; you could use a million different technologies to do this. It
really is about the workflows and the human factors,” said Dr. Hollander.

It also took time to find the best setting for the program. It first launched in 2015
on a comanaged hospitalist and oncology ward, but that wasn't a perfect fit. “Although
we thought they were people in the hospital for a decent duration of time and there
would be more confusing decisions being made. . . it turns out oncology patients are
getting chemotherapy and they're sick and vomiting, and they don't really want to
be on video,” he said.

Next steps

Jefferson's telehealth team is deciding which units should be next to implement the
program, with the ultimate goal of allowing all willing patients to participate whenever
they want, he said. “What we really need to do is embed it. . . in [each] unit's
workflow so that a device can be stored there, so that the software is licensed there,
so that it can be used when it needs to be used,” Dr. Hollander said. “Some
of the self-contained units, like the PACU and some of the ICUs, are where we've revamped
to target now,” since it can be more difficult for physicians to coordinate
with patients who are spread out over multiple general medicine wards.

Words of wisdom

Those who want to initiate a similar program should first find hospital units where
there are interested clinicians—and not just the doctors, Dr. Hollander suggested.
“Where are the unit clerks and nursing staff going to be most interested in
helping you champion this initially? Because once you win in some areas, everybody
else wants to play in the pond with you. But if you go to the wrong place first, it's
a lot harder to get people to jump in,” he said.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.